Healthcare Provider Details

I. General information

NPI: 1689323933
Provider Name (Legal Business Name): KIMBERLY LAMAR BONASSIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5511 GLADEHILL DR
HUMBLE TX
77345-2453
US

IV. Provider business mailing address

11511 SHADOW CREEK PARKWAY HR/CREDENTIALING SERVICES
PEARLAND TX
77584-7298
US

V. Phone/Fax

Practice location:
  • Phone: 512-947-7402
  • Fax:
Mailing address:
  • Phone: 713-442-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1089044
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number781598
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: